Pyoderma

Although pyoderma is common, the clinical signs can be overlooked. The lesions consistent with pyoderma include papules, pustules, collarettes, and patchy alopecia.

Pyoderma Management
Management of pyoderma requires recognition of the type and depth of infection and, in many instances, identification of the pathogenic organism in order to make appropriate treatment recommendations. Treatment usually involves the use of systemic antibiotics, often accompanied by topical therapy. Treatment choices vary depending on whether the pyoderma is a first-time infection or whether it is recurrent in nature. Treatment choices also depend on whether the infection is focal or generalized, surface, superficial or deep. eneral principles of antibiotic usage apply in all cases of bacterial skin infection. Antibiotic dosage should be based on the body weight of the animal and the full dosage administered. !ength of antibiotic administration should be " days past clinical remission in uncomplicated infections and #$#% days past clinical remission in complicated infections such as recurrent or deep infections and those associated with immunosuppression. This usually results in & to ' weeks of antibiotics for superficial infections and ( or more weeks for deep infections. )oncurrent steroid use is contraindicated when treating skin infections. )orticosteroids will mask the clinical response, making the lesions look resolved when they are not. This may result in discontinuation of the antibiotic too soon, encouraging the development of recurrent infections. *t will also interfere with diagnostic procedures. !ast, many cases of pyoderma have an underlying cause such as allergy or endocrinopathy. +emember to look for an underlying cause for all cases of recurrent pyoderma.

Factors to consider when choosing an antibiotic

)hoice of antibiotics will depend on many factors. These include the type of infection, depth of infection, the cost of the antibiotic, route and frequency of administration. ,otential side effects of the drug need to be taken into account. *n addition, the impact that the antibiotic may have on the normal flora may also need to be considered.

Empirical antibiotic selection

Antibiotics may be chosen without prior culture and susceptibility in a number of situations. -pecifically, antibiotics may be empirically chosen in uncomplicated superficial skin infections, in recurrent infections when the previous antibiotic choice successfully cleared the infection, and in deep infections pending culture and susceptibility results. .ecause Staphylococcus pseudintermedius /formerly known as -. intermedius0 is the most frequent organism isolated in canine skin infections, antibiotics chosen should have a known spectrum of activity against -taphylococcus spp. Antibiotics that should be avoided for empirical treatment of pyoderma include penicillin, ampicillin, amo1icillin, and tetracycline.

Antibiotic selection based on culture and susceptibility testing

)ultures should be obtained from all cases of deep pyoderma, skin infections that fail to respond to

empirical treatment, infections in dogs on immunosuppressive medications, infections in dogs with prior e1posure to many classes of antibiotics /eg. recurrent pyodermas0, and lesions in which intracellular rod bacteria are identified cytologically.

Antibiotic choices
2irst-line antibiotics are those antibiotics that may be chosen empirically or based on culture and susceptibility that target -taphylococcus spp. primarily with minimal impact on other bacteria. Antibiotics included here are erythromycin, lincomycin, and clindamycin. These antibiotics have a narrow spectrum of action and are considered bacteriostatic for most bacteria. They are generally effective when chosen empirically to treat first-time skin infections3 however, repeat e1posure to these antibiotics results in the development of resistance. *n addition, cross-resistance occurs among these three antibiotics. Therefore, use of these antibiotics to treat recurrent infections should be based on culture and susceptibility results. ,otentiated sulfonamide antibiotics /trimethoprim-sulfonamide3 ormetoprim-sulfametho1ine0 may also be considered as first-line antibiotic choices but their use should be avoided when long-term administration is required. ,otentiated sulfonamides are bactericidal and demonstrate good efficacy against ram-positive bacteria. .acterial resistance to this class of antibiotics is quite variable, ranging from $ to &&43 therefore, use of this antibiotic based on culture and susceptibility results may be more appropriate. -ide effects in dogs associated with potentiated sulfonamides include hypothyroidism, keratocon5unctivitis sicca, neutropenia, hepatopathy and polyarthritis. 6igh levels of resistance to tetracyclines e1ist in S. pseudintermedius3 therefore, this class of antibiotics cannot be regarded as a good empirical choice. 7et, do1ycycline has been used effectively to treat bacterial skin infections caused by susceptible strains. Therefore, because of its narrow spectrum of action, do1ycycline would be a good first-line antibiotic choice based on culture and susceptibility results. Many people use first-generation cephalosporins /cephale1in, cefadro1il0 as first-line antibiotics. These antibiotics are bactericidal and have a broad spectrum of action but primarily target gram positive bacteria. +esistance to this class of antibiotics is only now being identified. *deally, use of these antibiotics should be reserved for those cases in which culture and susceptibility indicate they are the antibiotic of choice. 2or cases in which there have been multiple antibiotic e1posures /e.g. recurrent infections0 and success of other antibiotics is questioned, then first-generation cephalosporins can be used empirically. Two third-generation cephalosporins, cefovecin and cefpodo1ime pro1etil, have recently been registered in the 8-A and 9urope. )efovecin is a long-acting in5ectable antibiotic which lasts #% days and cefpodo1ime pro1etil is an oral antibiotic that can be administered once daily. :hile both drugs offer good activity against staphylococci, their activity against S. pseudintermedius is not superior to first-generation cephalosporins. *n addition, they are active against a wide range of ram-negative bacteria. Therefore, their use has the potential for selection of both methicllin resistance in staphylococci and multi-resistant E. coli. *n spite of their convenient dosing, these drugs should only be used as first-line antibiotics if compliance is anticipated to be a problem. Amo1icillin with clavulanate is also a broad-spectrum bactericidal antibiotic that primarily targets ram-positive bacteria. *t, too, should be reserved for those cases of pyoderma in which culture and susceptibility indicate it is the preferred antibiotic. *n addition, it can be used empirically similar to first-generation cephalosporins.

-econd-line antibiotics should be based solely on culture and susceptibility results. Antibiotics included here include chloramphenicol, rifampin, and amikacin. )hloramphenicol is a bacteriostatic, narrow spectrum antibiotic. :hile it meets the criteria to be a first-line antibiotic, it is reserved for treatment of methicillin resistant S. pseudintermedius which are sometimes only susceptible to this antibiotic. )hloramphenicol is administered three times daily. *n addition to this inconvenient frequency of administration, it often causes gastrointestinal disturbances, is associated with drug interactions, and may cause bone marrow suppression. +ifampin is a bactericidal antibiotic with e1cellent tissue penetration. *t has a broad spectrum of activity against many ram-negative and most ram-positive microorganisms and is the most active antibiotic known against staphylococci. +esistance to rifampin readily develops with monotherapy3 therefore, it is best to use in combination with another antibiotic such as clindamycin or cephale1in. +ifampin is potentially hepatoto1ic and this side effect appears to occur more commonly in dogs than in people. Mild increases in alkaline phosphatase activity occur frequently and appear to be benign3 however, treatment should be discontinued if there are concurrent increases in other hepatic enzyme activities. ;ther rare signs associated with rifampin administration in dogs include thrombocytopenia, hemolytic anemia, anore1ia, vomiting, diarrhea, and death. Amikacin is an aminoglycoside that is not typically considered for treating dogs with skin infections. *t is an in5ectable antibiotic and is nephroto1ic. Therefore, use of this antibiotic is only based on culture and susceptibility results when no other antibiotic would be effective. Third-line antibiotics should be chosen last because of the pressure they place on bacteria in terms of selecting for antimicrobial resistance. These include the third-generation cephalosporins /see above0 and fluoroquinolones. :hile staphylococci often are susceptible to fluoroquinolones, resistance develops rapidly. *n addition, fluoroquinolone use appears to select for methicillin resistance. 8se of this class of antibiotics should be preserved for cases of deep infections associated with ramnegative organisms.

Topical therapy
Topical therapy may be used as both an ad5unct to systemic therapy or, in some cases, as the sole therapy for cutaneous skin infections. Topical therapy includes whirlpool baths, especially for dogs with deep pyodermas, and antibacterial shampoos. )hlorhe1idine, benzoyl pero1ide, and ethyl lactate containing shampoos all have demonstrated beneficial responses in dogs with infections. .athing should be done two to three times per week with a #$ minute contact time. *n a study using topical therapy alone to treat superficial pyodermas, '$4 of the cases were treated effectively when bathed three times per week. *n cases of recurrent or resistant infections, a topical chlorhe1idine spray is very beneficial when used once to twice daily. 2ocal lesions can be treated with chlorhe1idine spray, mupirocin ointment, benzoyl pero1ide gel, or fusidic acid /not available in the 8-A0.

Duration of therapy
!ength of therapy depends of the depth of infection and is determined by clinical cure. 2or superficial infections the average duration of therapy is & to % weeks with treatment continued # week past clinical cure. 2or recurrent superficial infections the average duration of therapy is a bit longer and is continued for #$ to #% days past clinical cure. <eep infections require ( to #= weeks of antibiotics with treatment continued = weeks past clinical cure. *f lesions recur within # week after discontinuing therapy, it is likely that treatment was not long enough.

*n order to determine if clinical cure is achieved, the dog should be re-e1amined before the antibiotic course is completed. <iscontinuation of therapy too soon leads to the selection of resistant bacteria. A common reason why pyodermas fail to respond to treatment or recur is if the length of therapy is too short.

Reasons for treatment failure

,yoderma may fail to respond to treatment if the bacteria are resistant or develop resistance to the chosen antibiotic. This may occur because an inappropriate antibiotic was chosen initially /e.g. amo1icillin0 or resistant bacteria were selected during the antibiotic course. As stated before, treatment failure also occurs if the antibiotic course was not long enough.

Management of methicillin resistant staphylococcal infections

An infection caused by methicillin resistant staphylococci is managed similar to management of any pyoderma. An antibiotic is chosen based on culture results. -taphylococci e1hibiting resistance to methicillin or o1acillin are also resistant to other penicillins, cephalosporins, and amo1icillin>clavulanate despite apparent in vitro susceptibility. ?ot all methicillin resistant staphylococci are multi-drug resistant. Typical antibiotic choices may include clindamycin, chloramphenicol, do1ycycline, minocycline, amikacin, and rifampin. 8nfortunately, antibiotic choices are becoming limited for some of the methicillin resistant Staphylococcus pseudintermedius /M+-,0. :e have managed some cases with aggressive topical therapy as the sole treatment. 8se of the antibiotics reserved for M+-A in people, such as vancomycin and linezolid, is ethically questionable. Staphylococcus pseudintermedius has been shown to colonize people temporarily, yet human infections with this organism are rarely reported. -ince -taphylococcus pseudintermedius is not a common human pathogen, the primary recommendation to owners involves frequent handwashing after handling their pets. There is a potential increased risk to immunocompromised members of the household, but this is not known. *t is likely that other pets in the household will be colonized with the same resistant bacteria3 therefore, pets with infections from households with known M+-, should always be cultured rather than empirically treated.

Recurrent infections
Reasons for recurrence
)ommon reasons for recurrent pyodermas include too short a duration of therapy, inappropriate dose of antibiotics, and concurrent glucocorticoids. *f lesions recur within # week after discontinuing therapy, it is likely that treatment was not long enough. *f the skin infection recurs after & to % weeks of discontinuing therapy, then there is likely an underlying condition predisposing the patient to infections that needs to be addressed. )ommon causes of recurrent infections include allergies and endocrinopathies. ;ccasionally, an underlying cause is not identified.

Managing idiopathic recurrent infections

Management of idiopathic recurrent pyoderma will depend on the frequency and severity of the infections. *f the infections only occur a few times per year, then each episode should be treated with antibiotics as described above.

*n some cases aggressive topical therapy can increase the interval between pyoderma episodes. ;wners can bath their dogs with antibacterial shampoos containing chlorhe1idine, ethyl lactate, or benzoyl pero1ide three times per week at the first sign of the infection returning. *n addition, chlorhe1idine spray can be applied to the infected areas. *n cases where the infection is severe, the goal may be to prevent recurrence of the infection. This can be attempted using pulse antibiotic therapy. The antibiotic is administered until the infection is cleared and then is given either at weekly intervals or every other day to prevent the infection from returning. .ecause of the increasing incidence of M+-,, pulse therapy is unlikely to be effective because it will select for resistant staphylococci. *mmune modulation with bacterins has been used to manage some cases of idiopathic recurrent pyodermas. .acterins contain various cellular products of staphylococci or other bacteria and are available commercially as -taphage !ysate /<elmont !aboratories0 and *mmuno+egulin /?eogen @et0. *n addition, some microbiology laboratories will make autogenous bacterins from the patientAs staphylococci. .acterins will not clear an e1isting infection and must be started concurrently with antibiotics. ;nce the infection is cleared, the antibiotics are discontinued while the bacterin is continued. *f the infection recurs, then a complete course of antibiotics will again be needed.

-umberB httpB>>www.vet.utk.edu>dermvet>pyoderma.php

Antistaphylococcal Antibiotics
Class Summary
-erious staphylococcal infections require treatment with parenteral penicillinase-resistant penicillin /eg, nafcillin, o1acillin0 or first-generation or second-generation cephalosporins /eg, cephale1in, cefuro1ime0 plus clindamycin. @ancomycin is reserved for staphylococcal strains that are resistant to penicillinase-resistant penicillins /ie, M+-A0 and clindamycin, or for when the patient has potentially life-threatening infection or into1ication. *n these situations, minimum inhibitory concentrations of vancomycin should be monitored.C#=(, #=", #=D, #=E, #&$, #&#, #&=F <ata for use of daptomycin in pediatrics are accruing. !inezolid is an alternative to vancomycin, C#&&, #&%F although resistance has begun to appear.C#&', #&(FTedizolid, a newer agent, has entered clinical trials. C#&", #&DF Telavancin is a newer lipoglycopeptide derivative of vancomycin for use in complicated skin and skin-structure infections and pneumonia.C#&EF?ewer derivatives include dalbavancin and oritavancin.C#%$F)eftaroline is a broad-spectrum cephalosporin with activity against M+-A that is in clinical trials.C#%#, #%=, #%&, #%%, #%'FAn old antibiotic, fusidic acid, is receiving renewed attention in the 8nited -tates for treatment of M+-A infections.C#%(, #%", #%DFMupirocin or retapamulin may be used for superficial localized infections /ie, impetigo0, although development of resistance may limit their utility.C#%EF @iew full drug information

Tela ancin !"ibati #

!ipoglycopeptide antibiotic that is a synthetic derivative of vancomycin. *nhibits bacterial cell wall

synthesis by interfering with polymerization and cross-linking of peptidoglycan. 8nlike vancomycin, telavancin also depolarizes the bacterial cell membrane and disrupts its functional integrity. *ndicated for complicated skin and skin structure infections caused by susceptible gram-positive bacteria, including S aureus /both methicillin-resistant and methicillin-susceptible strains0, S pyogenes, S agalactiae, S anginosus group, and E faecalis /vancomycin-susceptible isolates only0. @iew full drug information

Diclo$acillin

.inds to one or more penicillin-binding proteins, which, in turn, inhibits synthesis of bacterial cell walls. 2or treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when staphylococcal infection is suspected. @iew full drug information

%$acillin !&actocill#

.actericidal antibiotic that inhibits cell wall synthesis. 8sed in the treatment of infections caused by penicillinase-producing staphylococci. @iew full drug information

'afcillin !'allpen#

*nitial therapy for suspected penicillin Gresistant staphylococcal infections. 8se parenteral therapy initially in severe infections. )hange to ,; therapy as condition warrants. @iew full drug information

Cephale$in !(efle$#

2irst-generation cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis. .actericidal activity against rapidly growing organisms. ,rimary activity against skin flora. @iew full drug information

Cefuro$ime !Ceftin oral) *inacef in+ection#

.road-spectrum cephalosporin most closely resembling the second-generation cephalosporins. )efuro1ime is stable against beta-lactamaseGproducing organisms. @iew full drug information

Cefa,olin !(ef,ol#

2irst-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. ,rimarily active against skin flora, including S aureus. Typically used alone for skin and skin structure coverage. @iew full drug information

Amo$icillin and cla ulanate !Augmentin#

<rug combination treats bacteria resistant to beta-lactam antibiotics. 2or children H& mo, base dosage regimen on amo1icillin content. .ecause of different amo1icillin>clavulanic acid ratios in ='$-mg tab /ie, ='$>#='0 versus ='$-mg chewable tab /ie, ='$>(=.'0, do not use ='$-mg tab until child is H%$ kg. @iew full drug information

"ancomycin !"ancocin#

,otent antibiotic directed against gram-positive organisms and active against Enterococcus species. 8seful in the treatment of septicemia and skin structure infections. *ndicated in patients who are unable to receive or who have not responded to penicillins and cephalosporins or for infections with resistant staphylococci. 8se )r)l to ad5ust dose in patients diagnosed with renal impairment. @iew full drug information

Clindamycin !Cleocin#

!incosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci /e1cept enterococci0. *nhibits bacterial growth, possibly by blocking dissociation of peptidyl t+?A from ribosomes, arresting +?A-dependent protein synthesis. @iew full drug information

Daptomycin !Cubicin#

2irst of new antibiotic class termed cyclic lipopeptides. .inds to bacterial membranes and causes rapid membrane potential depolarization, thereby inhibiting protein, <?A, and +?A synthesis, and, ultimately, causing cell death. *ndicated to treat complicated skin and skin structure infections caused by S aureus /including methicillin-resistant strains0, S pyogenes, S agalactiae, S dysgalactiae, and E faecalis /vancomycin-susceptible strains only0. *ndicated for skin and skin structure infections. @iew full drug information

-ine,olid !*y o$#

,revents formation of functional "$- initiation comple1, which is essential for bacterial translation process. .acteriostatic against staphylococci. The 2<A warns against the concurrent use of linezolid with serotonergic psychiatric drugs, unless indicated for life-threatening or urgent conditions. !inezolid may increase serotonin )?- levels as a result of MA;-A inhibition, increasing the risk of serotonin syndrome.C#'$F @iew full drug information

Rifampin !Rifadin in+ection.oral) Rimactane oral#

*nhibits +?A synthesis in bacteria by binding to beta subunit of <?A-dependent +?A polymerase, which, in turn, blocks +?A transcription. @iew full drug information

Sulfametho$a,ole and trimethoprim !&actrim) Septra#

*nhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. @iew full drug information

Mupirocin !&actroban#

2or elimination of S aureus. *nhibits bacterial growth by inhibiting +?A and protein synthesis. @iew full drug information

Retapamulin !Altaba$#

Topical antibiotic available as a #4 ointment. 2irst of new antibiotic class called pleuromutilins. *nhibits protein synthesis by binding to '$- subunit on ribosome. *ndicated for impetigo caused by Staphylococcus aureus or Streptococcus pyogenes.

Cutaneous Abscess Empiric Therapy

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+eferences

Empiric Therapy Regimens

9mpiric therapeutic regimens for cutaneous abscess are outlined below, including those for inpatients and outpatients.C#, =, &F+ecommendations for prevention are also provided. 9mpiric therapy for cutaneous abscess typically involves incision and drainage, with or without the use of antibiotics Antibiotics should be considered in immunocompromised patients /including diabetes0 or in patients with systemic signs of infection /eg, fever or leukocytosis0 9mpiric antimicrobial therapy for more serious infections should cover methicillin-resistant Staphylococcus aureus /M+-A0

Treatment recommendations
Inpatient: @ancomycin #' mg>kg *@ q#=h or <aptomycin % mg>kg *@ daily or !inezolid ($$ mg ,; or *@ q#=h or )lindamycin ($$ mg ,; or *@ qDh Outpatient: )lindamycin &$$-%'$ mg ,; qDh for '-"d or

)ephale1in ='$-'$$ mg ,; q(h for '-"d or <iclo1acillin ='$-'$$ mg ,; q(h for '-"d or <o1ycycline #$$ mg ,; q#=h for '-"d or Trimethoprim-sulfametho1azole /#($ mg>D$$ mg0 <- #-= tablets ,; q#=h for '-"d

Pre ention
-anitation includes hand washing and good hygiene )ontrol of outbreaks may involve washing with chlorhe1idine soaps and washing of all clothes and towels M+-A carriage can be eradicated with nasal mupirocin and chlorhe1idine soaps

+ead more about )utaneous Abscess 9mpiric Therapy on Medscape +elated +eference Topics 2ungal *nfections in ,reterm *nfants <ental Abscess 9mpiric Therapy )utaneous Abscess ;rganism--pecific Therapy +elated ?ews and Articles .+A2 Mutation Testing Algorithm for @emurafenib Treatment in Melanoma +esection of a Methicillin-resistant -taphylococcus Aureus !iver Abscess in a ,atient :ith )rohnAs <isease 8nder *nfli1imab Treatment The Treatment of )utaneous Abscesses

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